The risks of emergency department overcrowding

A recent study has shown that those who present to emergency departments when waiting times are longer have worse outcomes.

Since 2008, Ontario has spent a lot of money and effort to reduce waiting times and improve the quality of care in emergency departments. Although significant progress has been made, much more remains to be done.

Emergency departments offer an essential service to the population, providing episodic care and treatment to people who are injured or require emergency care for other illnesses. Each year, there are over 5 million visits to Ontario’s emergency departments. Emergency departments are sometimes used as an alterative to primary care providers when people cannot see their family doctor or nurse practitioner, or do not have one. Overall, about 90% of patients who visit Ontario’s emergency departments are discharged after receiving care, with only about 10% admitted to hospital.

Emergency departments are often referred to as the canary in the coal mine of the health care system, because how well they appear to perform is affected by the rest of the system. For example, when there aren’t any available hospital beds into which to admit sick patients from the emergency department, or if patients do not have access to a primary care provider, emergency departments fill up and become overcrowded. Because of this, there are no easy solutions to reducing emergency department wait times.

Long waiting times for emergency department care are an issue across Canada – and in many other countries too – and emergency department waiting time has been identified as a priority for the Ontario government. Waiting time for emergency department care are not just an inconvenience; they have also been found to have an impact on patients’ outcomes.

Longer waiting times impacts patient outcomes

A new study by Ontario researchers has demonstrated that long waiting time not only affect patient satisfaction, they increase the risk of death and hospital readmission for patients who have been discharged from the emergency department. This study, published in the British Medical Journal looked at 22 million patient visits to Ontario emergency departments over a five year period, and found that the risk of death and hospital readmission increased incrementally with the degree of crowding at the time the patient arrived in the emergency department. The authors estimate that if the average length of stay in the emergency department was an hour less, about 150 fewer Ontarians would die each year.

The study findings imply that when emergency departments are full or overcrowded, processes of care change and quality declines. Howard Ovens, an emergency medicine specialist and director of the Mount Sinai Hospital emergency department says that the study findings “confirm what emergency department staff have always known, that an overcrowded, backed up emergency department is dangerous.” Ovens says that “doctors will spend less time with patients when there is a long queue, as they are trying to get caught up.” The authors of the study also speculated that spending less time with patients can mean time-consuming but important tests may not be ordered, observation times may be shortened and arrangements for follow-up after discharge may be incomplete.

What is Ontario doing about emergency department waiting times?

Michael Schull, an emergency medicine specialist and researcher, and a co-author of the study, says that the Ontario government has been a leader in Canada in “aggressively working to reduce emergency department waiting times” through a variety of different programs and policies.

One way that policymakers try to improve waiting time is through setting targets for the time patients ought to spend in emergency departments – this indicates to those working within the health care system that this is an important issue. Astrid Guttmann, the lead author of the study notes that setting targets for time spent in emergency departments was started in the United Kingdom, and has been controversial as “some say that waiting times are not clinically relevant.” In fact, the British government recently announced that it will abandon waiting time targets in favour of “more clinically relevant indicators.” These indicators, however, have not yet been identified.

Ontario is one of the first jurisdictions to implement system-wide targets for time spent in emergency departments. In 2008, the Ontario government introduced targets – they expect that 9 out of 10 patients will spend 4 hours or less in the emergency department if they have minor or uncomplicated conditions, and 8 hours or less if they have more complicated conditions and may need additional care and services, including hospitalization. It is important to note that this “wait time” is not the time a patient should wait before being seen, but the time from arrival in the emergency department to discharge. Hospitals have used a number of different approaches to help achieve these targets, says Ovens, including “the creation of rapid assessment units for less ill patients,” providing coaching to emergency department teams that want to perform better as well as “better matching staffing to patient arrival patterns,” to ensure that emergency department capacity can more appropriately meet demand.

The most recent waiting times for Ontario’s emergency departments are publicly reported online, and updated on a monthly basis. Since this information became available, emergency department waiting times have improved across the province. However many hospitals are still not meeting the targets.

Ovens says that “there is still a lot of work to be done [in Ontario], and that maintaining emergency department access and flow is a continual process.

How would you rate your most recent experience waiting for care in an Ontario emergency department?

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This article has been closed to comments. 14 comments

Chris CarruthersJuly 13th, 2011 at 10:01 am

Many emergencies still have long waiting times despite gov’t intentions. Little apparent consequences for not achieving designated wait times.
Some steps needed.
1.Patients in emergency waiting for a bed over a designated period of time get priority always over elective patients.
2. Experienced in patient nurses look after patients waiting for a bed not emerg nurses.
3. Paramedic/ambulance budget part of hospital budget to ensure hospital takes ownership of short turn around for ambulances.
4. Address ALC problem with more LTC beds.
5. Regularly bring in additional staff including docs when hit long wait times.

It would seem intuitive that the greater the back-log, over-crowding and chaos in the ED the less quality can be maintained. ER docs well know the stress of trying to multi-task, think and act while enduring the accusing stares from those in the waiting room (new designs make that less likely).
The frail elderly, often with as many social as medical challenges, do not find the ER a hospitable place and that is not surprising as the ER is neither constructed nor staffed to address the majority of their problems – applying speed performance targets to this population will not help as much as creating preventative and alternative, multi-disciplinary venues for their care.
Impeded flow of admitted patients out of the ERis a result of many factors – I always ask what the OR/elective surgery cancellation rate is (sometimes 0%!), what the bed management processes are and how closely CCAC is involved in discharge planning from the patient’s arrival in the ER.
While optimal LTC capacity is obviously important, there is good evidence that simply building more LTC beds will not solve our ALC issue; community resources will play a greater role.

Ambulance budget best out of City budget and into LHIN or regional health authority budget. Hospitals could be financially impacted if long waits for ambulances just like patients. Right now hospitals have no ownership of the problem and least costly and easiest for hospitals to have ambulances wait to unload their patients. The other day at our local hospital I counted 6 just waiting to unload. With these ambulances tied up therefore less on the road and then there is a request back to City Hall for more ambulances and paramedics ! Ambulances lined up in emergency is inefficient care and patients at risk.

In response to Sam – I refer to enhanced CCAC resources that enable seniors to be cared for at home, congregate and assistive living/supportive housing, programs such as Home First which has been shown to be highly effective. Furthermore, the Danish experience is telling – legislation passed in 1989 precluded capacity building in LTC and resources have since been oriented to home, or home equivalent, care. Also, when LTC capacity was last substantially increased in Ontario, beds filled rapidly and before too long, ALC patients had reappeared in significant numbers.

One issue that is rarely discussed with long wait times in emerg and patients waiting for in patient beds is the lack of bathroom facilities. Often 20-30 patients waiting for a bed may share 1=2 bathrooms. This is a real challenge in a environment of infections like c difficle

Totally free, excellent quality, acute care + liberal immigration policies = oversubscription. Start requiring modest co-pays from those that can afford it and from new immigrants and you’ll see (all usage) ER wait times and hospital LOS drop like a rock.

Recent immigrants to Canada use fewer health services of all kinds, including ER visits, than other Canadians. Copayments have been studied and have a minimal effect on care seeking, except they serve to dissuade those who cannot afford to pay.

Canada ranks near the bottom of eleven developed countries for ability to access primary care without going to the ER. What are those countries doing that we are not?

I think one of the major reasons for the long wait time at the Emergency Department is the lack of access to primary care. In GTA, many people still do not have family doctors and resort to ER for healthcare. Since these patients do not have a clear medical history filed at a family doctor’s office, the ER physicians probably need to conduct their assesment from scratch. This frustrates the ER physicians who are already stressed for time and take up valuable tools/resources that can be used for other patients in urgent conditions. Therefore, to avoid overcrowding at the Emergency Department, the government should try to increase access to the primary care facilities. This approach can not only decrease the number of patients requiring services from the Emergency Department (ie. decrease the demand) but also allow more efficient patient assessment process which can save time.

I was surprised to learn a few months ago that there are more patients without primary care physicians in Toronto than there are in most other parts of Ontario. This is paradoxical given that we hear again and again that physician shortages are most acute in rural areas. I am not sure why this is.

Although having a family doctor is a good thing, it’s probably not enough to bring down ED wait times substantially, especially since the kind of patients who show up at the ED because they don’t have a family doctor can often be cared for quickly and discharged from the ED.

The patients who languish in the ED the longest usually need to be admitted, and the reason they are stuck waiting for a bed in the ED is because the hospital is usually full, as other commenters have noted.

I agree with David Walker that ‘applying speed performance targets’ to the elderly may be unhelpful. This appears to have been the case in the UK, where the government is backing away from time-based targets now. Admittedly their targets have been much more aggressive – 4 hours for everyone, as opposed to our 8 hour target for complex patients. They also asked hospitals to get 98% of patients through within the 4 hour target, whereas we ask for 90% within 8 hours.

I work in an ER, so I know how crowded our ERs can be. This article strikes many important points. First, a lot of Canadians do not have access to primary care–I believe that 5 million Canadians are looking for a family doctor (correct me if this number is wrong). For these folks, the ER is the go-to center for any medical problems, regardless of the gravity of their ailment. Second, even those who have a primary care physician often do not have access in a timely manner. If I have sprained my wrist, for example, I don’t want to wait weeks to see a physician–I would immediately go to the ER. There needs to be implementation of clinical system that can deal effectively with less serious, but common problems that send people to the ER.

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital.